Remote Care Navigator

Seamlessassist; Tucson (AZ); Remote; USD 29,000 - 33,000; Full time

Job summary

Seamlessassist seeks a Remote Care Navigator for Cardiac to support medically complex patients with CHF. This full-time, non-clinical role conducts structured outreach, supports CMS-compliant care plans, and coordinates with RNs and cardiology teams.

Based in the United States with US hours and CST/PST overlap, you will use EHRs and care management tools to document activities, follow CMS standards, and help reduce hospitalizations through patient self-management.

Qualifications

• Active MA certification or LVN/LPN license required.
• Minimum 2 years of care coordination, case management or ambulatory care experience.
• Familiarity with CMS PCM, CCM and/or TCM program requirements and documentation standards.
• Proficient with care coordination software and/or EHRs.
• AI fluency and use of AI tools to improve efficiency.
• Based in the United States and eligible to work; US time zones required.
• Excellent written and verbal English with strong phone presence.

Responsibilities

• Conduct telephonic outreach to CHF and complex cardiac patients.
• Maintain a patient caseload using risk stratification for outreach priority.
• Complete initial assessments and follow-ups on symptoms, meds, psychosocial status and SDOH.
• Support CMS-compliant documentation and care plan updates.
• Escalate clinical concerns to supervising RN as needed.
• Coordinate with cardiologists and PCP offices as part of care team.
• Document time, interventions, care plans and patient goals per CMS standards.
• Participate in CMS-related dashboards to address care gaps.

Skills

Care coordination

CMS PCM/CCM/TCM familiarity

EHR proficiency

AI fluency

Phone communication

Education

Active MA certification or LVN/LPN license

Tools

EHR platforms

Care management software

Population health dashboards

CMS documentation tools

Job description

REMOTE CARE NAVIGATOR - CARDIAC

Sector

Healthcare - Cardiac Care Coordination

Reports To

RN Care Manager / Clinical Supervisor

Type

Full-Time · 40 hours/week

Schedule

Monday-Friday · Weekends -Flexible business hours (US hours, CST/PST overlap required)

Rate

$21-24 USD/hour (based on experience)

Contract

W-2

Location

100% Remote - US only (Dallas/Fort Worth area preferred)

Tools

EHR platforms, care management software, population health dashboards, CMS documentation tools

Role Overview

Our client - a cardiac care management MSO - is hiring full-time virtual Care Navigators to support a growing population of medically complex patients with cardiac conditions, primarily congestive heart failure (CHF). This is a non-clinical (non-licensed) role focused on telephonic patient outreach, care plan support, CMS-compliant documentation, and coordination across the care team. The Care Navigator works under the supervision of RN Care Managers, escalating all clinical concerns appropriately. This role plays a critical part in reducing avoidable hospitalizations and supporting patient self-management over the long term.

Key Responsibilities

• Conduct structured telephonic outreach to CHF and complex cardiac patients
• Maintain an assigned patient caseload using risk stratification to prioritize outreach
• Complete initial assessments and follow-ups covering symptoms, medications, psychosocial status, and SDOH barriers
• Support Transitional Care Management (TCM) follow-up within 48 hours post-discharge - medication reconciliation, red-flag symptom screening, appointment scheduling
• Provide patient education on CHF self-management and evidence-based strategies
• Monitor for signs of worsening conditions or care gaps and escalating to supervising RN
• Review and act on population health dashboards to address care gaps (wellness visits, labs, symptom monitoring)
• Document time, interventions, care plans, and patient goals per CMS billing standards
• Maintain proactive communication with RN Care Managers, cardiologists, and PCP offices
• Clinical assessment or medical diagnosis
• Medication prescribing or adjustments
• Interpretation of labs, imaging, or EKGs
• Clinical triage or emergency response
• In-person or home visit patient contact
• Billing or coding beyond required time-based documentation

Scope Limitations - This Role Does NOT Include

• Clinical assessment or medical diagnosis
• Medication prescribing or adjustments
• Interpretation of labs, imaging, or EKGs
• Clinical triage or emergency response
• In-person or home visit patient contact
• Billing or coding beyond required time-based documentation

Experience & Skills

Required:

• Active Medical Assistant (MA) certification or LVN/LPN license
• Minimum 2 years of experience in care coordination, case management, or ambulatory care
• Familiarity with CMS PCM, CCM, and/or TCM program requirements and documentation standards
• Technologically proficient with care coordination software and/or EHRs
• AI fluency - actively uses AI tools to work faster and more efficiently.
• Must be based in and authorized to work in the United States - time zone compatibility required (US business hours, CST/PST overlap)
• Exceptional written and verbal communication in English; strong phone presence assessed at screening

Preferred:

• Knowledge of cardiac conditions - especially heart failure and associated comorbidities
• Bilingual - Spanish/English (not a must)